This systematic review of handoffs from the emergency department to inpatient settings found that standardized handoff approaches led to enhanced perceptions of safety and satisfaction. Researchers found that little data exists on the impact of standardizing handoffs from the emergency department to the hospital on safety outcomes, but studies demonstrated the potential for provider education and implementation of standardized handoff tools to positively affect perceptions of patient safety and provider satisfaction.

Journal Article > Commentary

The Beers criteria serve as a standard guidance to inform prescribing decisions in older patients to protect against adverse drug reactions. Written by a registered pharmacist, this commentary relates insights regarding how use of the Beers criteria could have prevented a misdiagnosis in her elderly mother. The author highlights the responsibilities of pharmacists and prescribers to use the list as appropriate to ensure patient safety.

Newspaper/Magazine Article

Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.

Journal Article > Commentary

Implementing new information systems can have unintended consequences on processes. This commentary explores insights from a physician, both as a clinician and as the family member of a patient, regarding the impact of hard stops in electronic health records intended to prevent gaps in data entry prior to task progression. The author raises awareness of the potential for patient harm due to interruptions and diminishing student and clinician skill in asking questions to build effective patient histories.

Journal Article > Commentary

Mistakes during handoffs from the emergency department (ED) to inpatient units can diminish patient safety. This commentary summarizes how one hospital sought to to avoid miscommunications and disruptions by blocking admission of ED transfers during shift report. However, researchers found that blocking patient transfers did not result in improvements. The project did devise a standardized handoff process that was ultimately employed across the organization as a patient safety strategy.

This study examined the accuracy of using Google Translate to translate 100 actual, deidentified discharge instructions from English to either Spanish or Chinese. The majority of instructions were correctly translated (92% correct in Spanish, 81% correct in Chinese), as assessed by back-translation performed by bilingual human translators. Less than 10% of erroneous translations had potential to cause harm.

Journal Article > Review

The busy and complex emergency department environment harbors pressures can that hinder diagnostic safety. This review discusses the characteristics of emergency medicine that contribute to overreliance on heuristics and susceptibility to bias in decision making. The authors highlight the need to better monitor diagnostic error in the emergency department to inform the design of improvement activities. A previous WebM&M commentary discussed diagnostic delay in the emergency department.

This pre–post study examined the effect of an electronic health record alert that required physicians to respond "yes" or "no" regarding whether tests were pending at the time of discharge from the emergency department. Investigators found that physician responses were often inaccurate, and the proportion of discharged patients with tests pending increased following the intervention, contrary to intentions.

Newspaper/Magazine Article

This magazine article reports on the preventable death of a patient during an acute asthma attack. Written by the patient's husband, the article outlines the failures that led to her death despite the fact that she was at the door of a hospital emergency department and on the phone with an emergency dispatcher. Factors discussed include overreliance on poorly functioning technology, communication failures, and lack of fail-safes.

Maintaining accurate medication lists in the medical record and ensuring patient medication adherence remains an ongoing challenge. In this cross-sectional study, researchers tested the use of a mass spectrometry assay to identify medication adherence among 1346 patients across 3 different care settings. Mass spectrometry testing revealed discrepancies between medications listed as prescribed in the electronic health record and what patients were actually taking. The authors suggest that the use of such testing may be helpful in improving both the accuracy of medication lists and medication adherence.

This revised set of guidelines suggests standards to ensure high-quality care for pediatric patients in the emergency department, including a section on improving patient safety. Key recommendations focus on pediatric emergency care coordinators and implementing quality control mechanisms.

Successful initiatives that have enhanced the safety of handoffs have largely focused on the inpatient setting. This study determined that handoffs between outpatient pediatric providers and the emergency department at a single institution varied in quality, which can lead to unnecessary testing and other harm. A past Annual Perspective discussed how robust handoffs may improve safety outcomes.

Journal Article > Study

In 2015, the National Academy of Medicine called for renewed focus on reducing diagnostic error. Among patients admitted to the hospital shortly after discharge home from the emergency department, researchers found that 19% of cases involved a cognitive error, such as faulty information processing or inaccurate data verification, which may contribute to diagnostic errors.

Journal Article > Study

Clinical pharmacist supervision improves medication safety in many health care settings. In this study, pharmacists in a pediatric emergency department (ED) reviewed all discharge prescriptions the day after patients left the ED and contacted prescribers to address safety hazards. Over a 1-year period, pharmacists intervened rarely (0.25% of prescriptions), averted 10 incidents of moderate or major harm, and worked 45 additional minutes per day.